Prenatal Care Refresher - PowerPoint Presentation

Slide1

Prenatal Care Refresher

Liza van de

Hoef

, Registered Midwife

Ontario

Family Practice Nurses Conference

May 2, 2014Slide2

Disclaimers

No conflicts of interest, financial or otherwise

T

he midwifery perspective is the lens through which I view prenatal care

Historically

, Obstetrics has not been the most evidence-based

discipline

Many

interventions have been implemented

based on what expert opinion believed would be best,

and

later

was discredited

by

research

This presentation provides the SOGC guidelines, which are evidence based.

It is advisable to check with your consultants as to what is their preferred practice, or the practice in your communitySlide3

My Assumptions

You

have had previous education on prenatal

care.

You are providing care for low-risk women and are referring women who are high risk to an Obstetrician from the start of their

pregnancy.

The scope of your care is from pre-conception until 30 weeks approximately, and then resumes in the first week

postpartum.Slide4

Purpose

Briefly cover pre-conception counseling

Provide an overview of prenatal care from 8 weeks until approximately 30 weeks gestation

Briefly discuss postpartum care from birth until 6 weeks postpartumSlide5

Pre-conception

Folic Acid Supplementation

Low risk women should take a multivitamin with 0.4-1.0 mg folic acid for three months pre-conception

High risk women should take up to 5.0 mg daily

Risk factors:

Obesity

History of a previous pregnancy or family history of NTD

IDDM

Certain medications (

ie

. for seizure disorders)

Alcohol or drug addiction

Certain ethnic groups (Celtic, Sikh)

(SOGC

Pre-

conceptional

Vitamin/Folic Acid Supplementation

2007)

Discontinue hormonal birth control 3 months prior to conception

Lifestyle counseling: diet, exercise, limited alcoholSlide6

Initial visit (8-12 weeks gestation)

Health history (Antenatal 1 record)

Establish an estimated date of delivery (EDD)

Identify women requiring high risk prenatal care

Physical exam

Assess heart, lungs, thyroid, abdomen

Assess or discuss breasts and changes in pregnancy

Blood work

Discuss genetic testing options

Arrange ultrasounds as indicatedSlide7

Ontario Antenatal Records Slide8

Ontario Antenatal Records

“A Guide to the revised 2005 Ontario Antenatal Records

” - Ontario Medical

Association

Provides an overview of what each section/question is intended to

capture

http://

ocfp.on.ca/docs/default-source/cme/new-antenatal-record-and-guidef9a835f1b72c.pdf?sfvrsn=0

Of

interest, a new revision is possibly in the works. Primary care providers were asked for feedback in early 2014 regarding changes they would like to see to the records.Slide9

Allergies & Medications

Allergies

Include allergies to medications, food and products

Specifically important to note allergies to shellfish, latex, and kiwi/strawberries

Document reaction if it includes:

Hives,

angioedema

, itching/rash, shortness of breath, abdominal pain, diarrhea, vomiting

Medications – when it doubt, call

Motherisk

!

Health care providers or women can call to inquire about the safety or risk of medications (both OTC and prescription), chemical exposures, herbs, & foods

http://www.motherisk.org/women/index.jsp

(416) 813 - 6780Slide10

Estimated Date of Delivery (EDD)

This is one of the most critical parts of early prenatal care

“Determining length of gestation and accurate estimated date of birth can have profound personal, social and medical implications”

Association of Ontario Midwives Guideline #10 – Management of the Uncomplicated Pregnancy Beyond 41+0 weeks’ Gestation (2010)

Assumption is that human gestation is 40+0 weeks (280 days)

Three methods for establishing an accurate EDD:

Last Menstrual Period (LMP)

Conception

Early Ultrasound Slide11

Calculating an EDD - LMP

Either

Naegle’s

rule (add 7 days, subtract 3 months) or electronic calculator

Both methods assume 28 day menstrual cycle

Do not use OB wheel to establish due date

Errors by up to 5 days due to the size of wheel and loosening of the central mounting over time

Adjust date depending on the woman’s length of cycle

If menstrual cycle 30 days, add 2 days to EDD. If 26 days, subtract 2 days

Considered accurate if…

The woman accurately recalls first day of LMP (or has it recorded)

Her cycles were regular (less than 4 days variation month to month)

Her cycles were between 26-36 days in length

She was not on any hormonal birth control for the three months prior to conceptionSlide12

Calculating an EDD - Conception

Conception date

May know based on basal body temperature, IVF pregnancy, or purely logistics

Add 266 days to date of conception for accurate EDD.

Instead of doing the math, use one of the above methods with the conception date, and subtract 14 daysSlide13

Calculating an EDD – Ultrasound

Contradictory guidelines:

SOGC Guideline # 135

“The Use of First Trimester Ultrasound” (

2003):

Ultrasound

should not be used to date a pregnancy if the LMP is normal and

reliable

Dating ultrasound should be

performed between 8-12 weeks gestation for

accuracy

SOGC Guideline # 214 “Management

of Pregnancy at 41+0 to 42+0 Weeks” (

2008):

First

trimester crown rump length (CRL)

is

the gold standard for dating a

pregnancy

U

ltrasound should be

performed between 11-14 weeks gestation to coincide with IPS

testingSlide14

Calculating an EDD – Ultrasound

Notes of interest:

Ultrasounds which provide a gestational sac size but not a CRL are not considered accurate

If multiple 1

st

trimester ultrasounds, first scan with a CRL is considered most accurate

Some debate as to if ultrasound between 12-14 weeks are actually “first trimester” ultrasounds

Some community ultrasound clinics provide the CRL and then give you an EDD that does not correspond with the CRL.

We try to double check

all

CRL measurements on a reliable calculator to establish a final EDD.

http://www.perinatology.com/calculators/Crown%20Rump%20and%20Nuchal%20Translucency.htmSlide15

Calculating an EDD – My Practice

Use LMP if it is reliable based on the criteria listed above

Recommend an ultrasound

scan

between 8-12 weeks for dating if the LMP is unreliable

Offer a dating scan to

all

women in keeping with the 2008 SOGC guideline

C

hange the EDD if the date on the ultrasound differs from the date from her LMP by more than 5 daysSlide16

GTPAL

G

ravida

Number of pregnancies total

T

erm Deliveries

Number of

pregnancies carried past

37 weeks

Includes living and stillbirths

P

reterm Deliveries

Number of

pregnancies where birth is

between 20-37 weeks gestation

Included living and stillbirths

A

bortions

Included spontaneous losses and therapeutic abortions at <20 weeks gestation

L

iving Children

This is where multiple gestation is obvious. It is the only category where the number of

infants

is captured (vs. number of

pregnancies)Slide17

Obstetrical History

The records have spaces for the year of birth, baby’s sex, gestational age, birth weight, length of labour, place of birth and type of delivery

Under comments, helpful to include the following:

Complications of pregnancy (HTN, GDM)

Complications of birth (shoulder

dystocia

, PPH, episiotomy, degree of vaginal tear)

Complications with baby (admission to SCN/NICU, resuscitation, jaundice requiring phototherapy, slow weight gain)

Complications with mom postpartum (late PPH, dehiscence of stitches, breastfeeding troubles, PPD)Slide18

Medical History

#3 – Smoker: include if smoker or resides with a smoker

#6 – Dietary Restrictions: helpful to discuss with women what they should not eat in pregnancy (due to concerns regarding listeria)

Deli meat – have sliced at a reputable deli, consume within 4 days

Cheeses, dairy, honey and cider – safe to consume if pasteurized

Sushi – buy at places where fish is flash frozen prior to preparation.

Dense fish (shark, salmon, tuna) – no more than once a month due to mercury

Canned tuna, shellfish – no more than twice a week

Avoid alfalfa sprouts, raw or undercooked meat, raw eggs, and meat spreads/pates

May be a good time to discuss Toxoplasmosis also…

Do not change cat litter, wear gloves when gardening, wash all vegetables prior to consuming.Slide19

Medical History

#18 – Anesthesia Complications: include family history of complications

F

ever, inability to wake, vomiting, lack of effectiveness

#

21 –

Other: musculoskeletal problems (

eg

.

Scoliosis

)

#24 – Psychiatric history: include history of eating disorders

# 31-37

–

Psychosocial questions

Important to ask about history of rape or assault

History of sexual abuse, assault or rape can significantly affect women during pregnancy and birth.

Excellent resources are available, including counseling if indicated

E.g. “When Survivors Give Birth” by Penny

Simkin

Should ask EVERY woman about domestic violence

25% of Canadian women have experienced physical violence from an intimate partner

21% of women abused by a partner were assaulted while pregnant

43% of these women experienced their first episode of assault while pregnant

Severity and frequency of abuse often increases postpartumSlide20

Cervical Cytology (Pap Testing)

If the woman is low risk, and normal

cytology

previously,

not

recommended to do a pap

test in

pregnancy or postpartum unless it has been 3 years since her previous

test

The

absence

of T-zone cells

is

not

an indication to do a

pap test

sooner than 3 years

Ontario Cervical Screening Cytology Guidelines Summary, May 2012

No evidence to link

pap testing with

miscarriage. However, due to the friability of the cervix, many women do have some spotting and subsequent psychological stressSlide21

Initial Blood work

Recommended blood work includes:

CBC

Type and Screen

Public Health Tests

Rubella Immunity, Hepatitis B surface antigen, HIV and VDRL

Optional blood work:

TSH – should be routinely checked

Especially important if woman has strong family or personal history of thyroid problems.

Random Glucose – no longer recommended

GDM testing may be indicated – see later discussion

Ferritin

Used by some practitioners to identify women with anemia

Parvovirus

Immune status may be helpful to have on file if the woman works with or has young childrenSlide22

Genetic Testing

Integrated Prenatal Screening (IPS) = most accurate

Ultrasound for

nuchal

translucency and blood work at 11-14 weeks gestation, repeat blood work at 15-19 weeks gestation

First Trimester Screen (FTS)

Ultrasound for

nuchal

translucency and blood work at 11-14 weeks gestation

Serum Integrated Prenatal Screen (SIPS)

Blood work at 11-14 weeks and again at 15-19 weeks

Maternal Serum Screen (MSS)

Blood work at 15-20 weeks gestation

Maternal Screen Alpha-Fetoprotein (AFP) only

Blood work at 15-20 weeks gestationSlide23

Genetic Testing

Purpose: to provide women with their risk of having a baby with Down Syndrome, Trisomy 18, or an Open Neural Tube Defect (NTD)

Screening tool only – diagnostic testing required to confirm results

For Down Syndrome and Trisomy 18, diagnostic testing is an amniocentesis

Risk

of miscarriage associated with

amniocentesis

is approximately 1/200

For Open NTD, diagnostic testing is usually a tertiary care ultrasound of the spine

The most accurate of tests (IPS) detects about 85-90% of babies with Down Syndrome (and misses 10-15%)

There is also a 2-4% false positive rateSlide24

Initial Visit – Discussion Topics

Nausea & Vomiting

Many good non-prescription management options

Small frequent meals

Do not consume large amounts of fluid at one time

Anti-nausea bands for pressure points on wrists

Ginger! Tea, ginger ale, capsules, lozenges

Acupuncture

Gravol

is considered safe

Diclectin

Prescription medication

P

regnancy class A

Up to 6 tablets/day are considered safeSlide25

Subsequent prenatal visits

Recommended visit schedule:

Every 4 weeks from 8-28 weeks gestation

At each appointment, should document:

Maternal weight

Urine dipstick – Protein only

Glycosuria is not considered an accurate measurement of sugar metabolism, and is no longer recommended for testing in pregnancy.

Gestational age (using an OB wheel is fine)

Blood pressure

Fundal height (after 20 weeks gestation)

Useful to plot on chart in lower left corner of AN 2 for normal reference range

Fetal heart beat (after 12 weeks gestation)

110-160 bpm considered normal, though typical to see 160-170 in first trimester.

Fetal movement (after 18-20 weeks gestation)

Fetal position (after 24-28 weeks gestation)Slide26

Second Visit – Clinical Testing

Sexually Transmitted Infections - Urine testing

Sensitivity and specificity are closely comparable between urine and cervical testing.

http://www.lifelabs.com/files/InsideDiagnostics/InsideDX_March2011-FINAL.pdf

Mid-Stream Urine (MSU)

Recommended that women perform a MSU in the second trimester (usually around 15-18 weeks) to check for asymptomatic urinary tract infections (UTI)

Should be done each trimester for women with a strong history of UTI, or if women are symptomatic,

If the woman has a history of preterm

labour

, MSU and vaginal swabs for bacterial

vaginosis

should be done every trimesterSlide27

Second Visit – Discussion Topics

Weight Gain in pregnancy

Current

guidelines

based on a woman’s pre-pregnancy BMI

Underweight (BMI <18.5 ) = 28-40 lbs

Normal weight (BMI 18.5-25) = 25-35 lbs

Overweight (BMI 25-30) = 15-25 lbs

Obese (BMI >30) = 11-20 lbs

(Institute of Medicine & National Research Counsel guideline, 2009)

Diet, Exercise, Prenatal Education

Healthy Babies Healthy Children Screen

Requested by the public health unit to be completed on every pregnant woman at

first prenatal appointment

and

again after the birth

Optional – women must consentSlide28

18-20 weeks – Clinical Testing

Anatomy ultrasound

Ultrasound should only be used when medical benefits outweigh any theoretical or potential risk

Should not be done for non-medical reason (

e.g

sex determination)

Exposure should be as low as reasonably achievable (2D)

“No proven adverse biological effects associated with diagnostic ultrasound…(however) one must be cognizant of the potential for a yet unidentified risk”

SOGC Guideline # 160“Obstetric Ultrasound Biological Effects and Safety” (2005)

Should discuss with women that the purpose of the ultrasound is a genetic screen: to check for abnormalities in the baby and/or placenta

If EDD established by LMP or conception date, and EDD from this ultrasound differs by more than 10 days, should change EDD.Slide29

Abnormal Ultrasound Results

“Clinical Significance and Genetic Counseling for Common Ultrasound Findings” – National

Society of Genetic Counselors Prenatal Special Interest

Group

(

2009)

http://nsgc.org/p/cm/ld/fid=232

13 pages of reproducible handouts

Information and recommended follow up for:

Hyperechoic

Bowel, Choroid Plexus Cyst, Club Foot,

Intracardiac

Echogenic

Focus, Soft Markers for Down Syndrome, Shortened Long Bones, Increased

Nuchal

Translucency, Single Umbilical Artery, Cleft Lip and/or Palate,

Hydronepherosis

, Mild

Ventriculomegaly

, Cystic

Hygroma

Also SOGC Guideline # 162 “Fetal Soft Markers in Obstetric Ultrasound” (2005)Slide30

Placenta Previa

Low lying placenta = within 20 mm of the cervical

os

Almost always moves away by term

Placenta

Previa

= placenta overlaps cervical

os

Overlap of more than 15 mm associated with increased likelihood of placenta

previa

at term

S

hould arrange for follow up ultrasound for placental position at 28-30 weeks gestation

May wish to request

transvaginal

ultrasound for distance to cervical

os

if low-lying.

Contraindicated if complete

previa

No evidence to support decreased lifting, discontinued intercourse, or bed rest

A

dvise woman to present to nearest obstetrical unit with any copious vaginal bleeding (more than spotting)

SOGC Guideline #189 “Diagnosis and Management of Placenta Previa”Slide31

18-20 weeks – Discussion topic

Preterm

Labour

(PTL)

Signs and symptoms include dull backache, rhythmic cramping or contractions (<10 minutes apart), vaginal bleeding or rupture of membranes

Should present to nearest obstetrical unit for assessment

Fetal

fibronectin

(

f

FN

) –

Can be done between 24-34 weeks gestation

A

ccurately

identifies women

not

in

PTL. Less accurate at correctly identifying those

in

PTL

If

fFN

positive, women often admitted to tertiary care unit for observation (unless delivery imminent) Slide32

24-28 weeks – Clinical Testing

Glucose Testing

No universally guidelines

SOGC

3

options: screen everyone, screen no-one, or screen based on risk factors

SOGC Guideline # 121 “Screening for Gestational Diabetes” (2002)

Canadian Diabetes Association

All pregnant women should screen.

CDA Clinical Practice Guideline “Diabetes and Pregnancy” (2013)

Risk factors include:

A

ge >25 (CDA = age>35)

R

acial group prone to GDM (e.g. Indigenous)

Pre-pregnancy BMI >27 (CDA = BMI >30)

Personal history of GDM

F

amily history of diabetes (first degree relative)

Previous infant >9 lbs

P

revious unexplained stillbirthSlide33

24-28 weeks – Clinical Testing

Oral Glucose Challenge Test (OGCT)

Screening test

Performed at 24-28 weeks gestation

50 gram sugar drink, followed by a blood draw 1 hour later

Normal results <7.8

mmol

/L

If 7.8-10.2

mmol

/L, recommend OGTT

If >10.3

mmol

/L, diagnostic of GDM

Oral Glucose Tolerance Test (OGTT)

Diagnostic test

Requires woman to fast for 12 hours prior to drink

Blood draw at baseline, 1 hour and 2 hours

If 1/3 results elevated, diagnosis is “Glucose intolerance”

Nutritional counselling recommended, as well as daily blood sugar monitoring

If 2/3 or 3/3 results elevated, a referral should be made to your consultant ObstetricianSlide34

24-28 weeks – Clinical Testing

If women at particularly high risk of GDM, should offer testing at booking visit and repeat at 24 weeks

“High risk” not well defined

Can do early testing via OGCT or OGTT (evidence to support both)

Women with GDM in pregnancy should be tested again at 6 weeks postpartum with an OGCT

Reported benefits of Glucose testing:

Reduction in perinatal mortality, identification of women at risk for future Type II diabetes, and opportunity for lifestyle change and education

Most women who are diagnosed with GDM will be induced around 39 weeks to decrease the chance of stillbirth

Some controversy around glucose testing in pregnancy

OCGT has a 16% false positive rate, and 1-3% false negative

Dependent on cut-off values used, which there is no universal support for

Lack of quality research to support the claim that diagnosis of GDM reduces perinatal mortality

Some women develop GDM later in pregnancy (>30 weeks), which the 24-28 week test misses completelySlide35

24-28 weeks – Clinical Testing

Additional blood work

CBC &

Ferritin

Identify women who are anemic, recommend supplementation

Rubella

If initial blood work showed the woman was Rubella indeterminate, often a repeat Rubella titer at this time will show immunity

Type and Screen (done at 28 weeks)

If your patient is Rh Negative, she may require

WinRho

Most hospitals require a repeat type and screen, and repeat antibodies to be done prior to

WinRho

administration

It is important to tell women that

WinRho

is a blood

product

Some women may have religious objections to receiving

this

Women

may choose to have their partner’s blood tested if they are confident of

paternity

If the father is Rh negative also, the baby will be Rh negative and

WinRho

is unnecessarySlide36

24-28 weeks - Discussions

Fetal

movement

Baby should move daily and

regularly

If the woman is concerned, she should drink something sweet and cold, lie down and

count movements

Should feel ≥6

in a 2 hour

period

Seek

immediate assessment

if baby does not move accordingly

Hypertension

Signs/Symptoms include severe frontal/ocular headache, non-temporary vision changes (blurry, spots, sparkles), right epigastric pain

Women experiencing these symptoms should have their blood pressure assessed by a health care provider

More common for women having their first baby, or first baby with a new partner, and women who have previously had trouble with

hypertensionSlide37

24-28 weeks

A

rrange

follow up ultrasound as

indicated

May want to discuss topics like breastfeeding and infant care, since you won’t see them again until postpartum

Arrange consultation with local specialist as per your protocol!Slide38

Postpartum Newborn Care

Circumcision is no longer recommended by the Canadian Pediatric Society, and has been delisted from OHIP

Excellent resource on youtube.com called “Circumcision: The Whole Story”. Produced by the Barrie Midwives

Discusses historical reasons for circumcision, statistics, debunking of myths, and the impact of circumcision on the infant and adult penis

Breastfed infants should gain minimum of 5

oz

/week, and ideally gain 1

oz

/day

World Health Organization Child Growth Standards

Breastfed baby growth charts show that babies who are exclusively breastfed for at least 4 months follow a different trajectory than those formula fed

Endorsed by the Canadian Pediatric Society

http://www.dietitians.ca/Secondary-Pages/Public/WHO-Growth-Charts.aspxSlide39

Postpartum Maternal Care - Physical

Normal bleeding:

H

eavy period bleeding for 24 hours

Moderate bleeding for 7-10 days

Taper to light bleeding at 1-2 weeks

Decrease to spotting or

coloured

discharge

Most women are done bleeding by 4 weeks

May consider ordering an uterine ultrasound for retained products of conception if bleeding more than spotting at 4-6 weeks postpartum

Bladder control

It is NOT normal to have lowered bladder control after having a baby!

E

ncourage women to seek help if it is ongoing after 6 weeksSlide40

Postpartum Maternal Care - Mood

Approximately 80% of women experience postpartum adjustment

Feeling “overwhelmed”

T

ypically resolves without intervention by 4 weeks postpartum

12-16% of women experience postpartum depression

Risk factors include personal history of depression, strong family history of depression, additional stressors in life, or if their birth/postpartum goes very differently then they planned

Teen mothers are at highest risk (25%)

Characterized by overwhelming sadness, hopelessness, and despondency. May also manifest as anxiety, anger or irritability

Edinburgh Postpartum Depression Scale

Concerning results >10

These women often need intervention (e.g. support, counselling, medication)

Canadian Mental Health AssociationSlide41

Questions and Comments?Slide42

Thank

You!